Health inspection·October 17, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's central line intravenous (IV) catheter was maintained per the facility policy. This affected one (#87) of two residents reviewed for having IV catheters. The facility census was 68. Residents Affected - Few Findings include: Review of Resident #87's medical record revealed the resident was originally admitted on [DATE] and had a readmission on [DATE] with diagnoses including acute cholecystitis, hemiplegia, and diabetes. Review of the physician orders for Resident #87's dated 06/07/23, revealed the resident had a [NAME] vascular central intravenous (IV) access catheter to the chest wall. The orders revealed no other documentation for the central line to be maintained and/or cared for by staff. Review of the hospital's discharge notes for Resident #87 dated 08/08/23, revealed the resident was discharged to the facility with a double lumen central line catheter in her right upper chest wall and to continue the IV care per nursing protocol. Review of the medication administration records (MARS) and treatment administration records (TARS) from 08/08/23 to 09/18/23 for Resident #87, revealed no documented evidence the resident's central line catheter was maintained and/or cared for according to the facility policy. Review of the nurse's progress notes from 08/08/23 through 09/18/12 for Resident #87, revealed no documented evidence the resident's central line catheter was maintained and/or cared for. Review of the admission nursing assessment for Resident #87 dated 08/09/23, revealed no documented evidence the resident was admitted with the double lumen central line catheter and/or orders obtained to maintain and/or care for the resident's central line catheter. Review of the physician's progress notes dated 08/15/23 for Resident #87, revealed no documented evidence of orders for the staff to maintain and/or care for the resident's central line catheter. The note indicated to continue all medications and orders per the plan of care. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 09/15/23 for Resident #87, revealed the resident had intact cognition. The assessment revealed no documented evidence that the resident was assessed to have a central line catheter. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366477 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)